July 12, 2008

Soft-tissue injuries can be dramatic and grotesque. For this reason, even injuries that aren’t life-threating in themselves can prove deadly by distracting rescuers from the actual life-threatening injuries, particularly airway and breathing problems.

Let’s start at the ends of the extremities and work in toward the core of the body. That way we’ll be working from less-life-threatening to more-life-threatening, though I do expect digressions and nothing is 100%. I’m going to talk about the signs, symptoms, and basic first aid. Remember that I am not a doctor, I can neither diagnose nor prescribe, and nothing here is meant to be advice for your particular condition or situation. This post is presented for entertainment purposes only.

So: first thing. Traumatic amputation. This can range from fingers or toes on up to hands and feet or entire limbs. The typical person who suffers a traumatic amputation is male (80%), between the ages of fifteen and thirty, and has just said, “Hey, Bubba, watch this!” (No, actually and seriously, farming and factory accidents are the most common causes of traumatic amputation.)

I wasn’t entirely sure whether to put traumatic amputations in this part of Trauma and You (soft tissue) or in the last part (skeletal injuries). What convinced me to classify it over here was that the treatment for amputations is more like the treatment for soft tissue injuries than the treatment for skeletal injuries, even though there’s injury to the bones.

You’ve got two kinds of traumatic amputations: Partial and complete. I trust these are self-explanatory. If you have a partial amputation (“Hanging on by a thread”) do not complete the amputation. It’s possible that whatever tissue is still connecting the part is sufficient to maintain perfusion.

The blood loss from an amputation may be minimal: this is because of the makeup of veins and arteries. Veins have two layers, the tunica intima and tunica adventitia (which are Latin for “Underwear” and “Overcoat”). Arteries, which handle higher pressures, have three layers, the tunica intima, tunica media , and tunica adventitia.

The tunicae media of an artery, and the tunica adventitia of a vein is muscular; in the normal body the contractions of these muscles control how the blood flow is directed to the organs that need it most.

Muscles have only one trick: When stimulated they contract; that is, they get shorter and thicker. A cut or torn artery or vein has, at its cut end, a whole lot of stimulation of the muscles. They contract, and close off the vessel. Blood pressure in the arteries may be high enough to push past the contraction, so what we do is apply direct pressure to the injury site until clotting can start.

The general solution for any bleeding is direct pressure.

Assume that your patient is either in shock or will shortly be going into shock. Treat for shock. Do not neglect airway, breathing, and circulation.

So, you’re applying direct pressure to the raw stump on your patient. You’ve got his airway under control, he’s breathing fine. He’s lying down and wrapped in a blanket. He’s going to live. What you do on-scene now will have a critical impact on whether the amputated part can be surgically reattached.

This is the critical part. Find the amputated body part. Remove gross contamination. Wrap it in a clean dry cloth. Put it in a plastic bag. Label it with the patient’s name. Put the plastic bag in a container with ice water. The idea is to keep it cold (but not frozen), and dry. Transport the amputated part in the same ambulance as the patient.

Don’t delay transport, however, to look for a missing part.

Next up in the Soft Tissue Injury Hit Parade is the degloving injury.

As you know, Bob, the skin lies on top of the layers of muscle and is only loosely attached. So it’s possible to remove the skin from, say, a hand in the same way that a glove comes off a hand (hence the name of the injury). The last time I saw a degloving it involved a gentleman who was attempting to adjust a belt on a running lawnmower.

Treat it as you would an amputation. (Note: hands and feet aren’t the only things that can be degloved. That’s an important safety hint for the gentlemen who might consider a vacuum-cleaner hose to be a sex toy.)

Speaking of penes, did you know that it’s possible to fracture one? It has to be fully erect and … snap! The usual mechanism is vigorous sex in the female-astride position with a lady not his wife. Treat with direct pressure. And listen to the gent call his wife from the ER and explain what happened and how it happened. (“There I was, walking along, minding my own business….” It’s as much fun as (though considerably rarer than) listening to a gent explain how some object got stuck in his rectum.)

Similar to a degloving is the avulsion. That’s essentially taking a divot out of the flesh. Like amputations, these can be either partial or complete, and, like amputations, you don’t want to complete a partial avulsion.

The first thing you’ll notice is that tissue is missing. The next thing you’ll notice is that the wound is bleeding heavily.

What to do: Place the avulsed part back into the hole it was gouged out of, and apply direct pressure.

An exception to this is the avulsed eyeball. You don’t want to apply pressure to an eye. For avulsed eyes, place it back in its socket, and cover it with a paper cup. I’ll probably do a whole post on eye injuries later on. For right now: If one eye is injured, cover both eyes. Eyes move as pairs, and the good eye tracking things will make the injured one move, possibly making the injury worse. The patient is now blind, and hurt, and may well panic. So from the moment you’ve covered his eyes you need to have someone with him, literally holding his hand and talking constantly, explaining what’s going on around him and what will be happening next.

Again, remember, your patient either is already in shock or is going into shock. Treat for shock early, and maintain the airway, breathing, and circulation.

Another way soft-tissue injuries are classified is as blunt or penetrating trauma. The difference between the two is whether the skin has been broken. So far I’ve been talking about penetrating trauma — for amputations, degloving, and avulsions the skin is broken and you can see external bleeding.

Let’s talk about a blunt injury. Compartment syndrome. The reason I’m talking about it here, as we march up the arms and legs toward the trunk is because the most common places for compartment syndrome to appear is in the forearms and in the lower legs. Unlike the very-obvious injuries we’ve just been talking about, this one wasn’t even recognized until the last half of the 19th century.

As-you-know-Bob, the muscles in the limbs are arranged into bundles separated by fascia. The fascia are thick, non-elastic layers of tissue. They form compartments inside the limb that hold muscle bundles, nerves, and blood vessels. Bleeding inside one of these compartments can result in the compartment filling up with blood, forming, in effect, an internal tourniquet. At some point the pressure inside the compartment will exceed the pressure inside the capillaries in the compartment. They collapse. Perfusion ceases. This leads to tissue ischemia, then tissue death. This is limb-and-life threatening.

The cure for compartment syndrome is surgical. Nothing you can do for it in the field. The primary symptom is pain. A whole lot of pain. Far more than you’d expect from the appearance of the injury. The second major symptom is paresthesia (“pins and needles” or numbness), as the nerves (very sensitive to loss of oxygen) shut down. This even happens in a known order: for example, in compartment syndrome in the anterior compartment of the lower leg, the first place you lose feeling is in the web between the first and second toes.

So you take a hit to the leg while you’re roller-blading and a couple of hours later your calf really-really hurts and your foot falls asleep. Dude, get your skinny young butt down to the ER pronto.

Since we’re sort-of there already, it’s time to talk about crush injuries in general. You see them in prolonged entrapment, compromised circulation, and blunt trauma to muscle mass. 40% of your survivors from a collapsed building will have crush injuries. Between 3% and 20% of earthquake survivors will have crush injuries. (You also see crush injuries in drug overdoses: a guy passes out with his head on his forearm, or with his leg bent under his body, and stays in that position for hours.) What happens in crush injuries is this: the damaged muscle releases myoglobin (that’s the protein that makes red meat red) and potassium. When circulation is restored to the limb, the myoglobin kills the kidneys (ARF: Acute Renal Failure) and the potassium induces possibly-fatal cardiac arrhythmias. Look for tea or cola-colored urine.

The treatment in the field for this is establishing an IV and putting a whole lot of normal saline into the patient, and starting it before the extrication is complete. This is to dilute the nasty black poisonous blood that’s going to go into central circulation as soon as the patient is extricated. A first-aider with what he’s got in his pockets won’t have that. Call the pros.

When crush injuries were first identified (in the trenches of WWI and the London Blitz of WWII) they ran around 90% fatal. Nowadays with fast and efficient EMS they’re down to 50% fatal.

Shall we talk about complex extremity injuries? You see these in industrial accidents, in motorcycle crashes, in ejections from cars, and automobile-vs-pedestrian collisions. These are pretty scary looking. The technical term is “a mess.”
(I’m not making that up: when you get the patient to the ED, the doctor on duty will figure out the MESS (Mangled Extremity Severity Score) .)

What do you do? Nothing much. While these are the sort of injuries that make bystanders faint, they are comparatively simple to deal with. Control bleeding with direct pressure, and do not allow yourself to be distracted from controlling airway, breathing, and circulation. Treat for shock. (For the patient, the bystanders, and yourself. One time when I was teaching soft-tissue injuries to a group of firefighters one of the men passed out while we were looking at slides. I’d just said something like, “That looks like a thumb, so the elbow has to be somewhere around here…. when ka-thump, down he went. This was great practice. Put coats over him, raised his feet, applied oxygen (doing this in a fire station means all those things are readily available.) Be aware that if your own heart rate goes up, your breathing goes up, and you start sweating, you may be going into shock yourself.)

Let’s talk about direct pressure for a moment. As I’ve said, this is the best way to control bleeding. You place your (gloved) hand on the wound, and press harder than the patient’s systolic blood pressure.

Okay, as soon as practical, put on a clean cloth dressing, and press on that. If it soaks through, put on another cloth on top of it. (Reason you don’t remove the soaked dressing: soft clots will be forming. If you remove the dressing you’ll lose them.) Continue until bleeding stops.

In complex injuries you may not be able to tell where the bleeding is coming from, and they may be too large for you to put pressure on the entire thing. Here’s a trick: Flush the wound with water and see where the bleeding starts from first. That’s where you’ll press.

Now it’s controversy time: In the system I work in, if direct pressure isn’t working you go on to elevation of the limb above the heart, then to pressure points (pressing on an artery above the injury). I’m not allowed to use tourniquets. However, PHTLS (Pre-Hospital Trauma Life Support) Sixth ed. teaches that if direct pressure isn’t working you should go directly to tourniquets. The thinking is that an arm or leg can last two hours without circulation, but the patient himself can last perhaps five minutes without blood. And since the priority is life before limb … don’t screw around with elevation and pressure points (which aren’t all that likely to work anyway in a situation where direct pressure has already been tried and failed).

What should you do as a first-aider? Let your conscience be your guide. If you use a tourniquet it goes over a long bone (not a joint!) above the injury. It’s wide, it’s soft, it’s cranked down until bleeding stops, and it’s left in place until it’s removed at the hospital. Make the tourniquet obvious to the next providers to take over: leave it exposed rather than covered by blankets. Write the letter “T” followed by the time (24-hour clock) on the patient’s forehead with your Sharpie marker, some lipstick, your car keys … whatever comes to hand. And treat for shock.

Let’s move to more pleasant thoughts. Lacerations and incisions. (We’re getting now to things that can happen anywhere on the body.) The difference between a laceration and an incision is this: A laceration is when the skin splits due to a blow or tears on something, while an incision is a cut on something sharp (broken glass, torn metal, a knife… like that). A laceration has uneven depth and ragged edges. An incision has a consistent depth and straight edges. As above, for either, control bleeding with direct pressure.

For a large laceration consider splinting the injury. The energy needed to lacerate the skin might be enough to fracture underlying bone. The opening may be a sign that you have an open fracture and may have been caused by a sharp bone end. And in any case, splinting will reduce skin motion and keep the laceration from being torn wider.

Suppose you’re in the woods, two weeks from the nearest hospital, and you have a laceration. What do you do? You want it to heal from the bottom up, so you don’t encapsulate crud inside you. Take a clean cloth, lay it in the wound, leaving a wick protruding. Bind it up with another cloth. After a while this will get all funky and nasty. Take out the wick, wash out the wound, lay in another cloth (with wick) and bind up. Repeat until the entire thing is healed. This will leave a heck of a scar, but at least you won’t have a chronic infection. If you happen to get maggots in the wound, leave them. The only thing they’ll eat is dead tissue, and you want that to happen.

Milder stuff: Contusions. That’s the fancy word for a bruise. That’s capillary bleeding under the skin from blunt trauma. In earlier stages, contusions appear pink or slightly reddened. Later they take on the typical purple coloring. Later still (as the blood breaks down) they turn greenish or yellow. Bruises can travel downhill: A bruised area on the ankle might be a sign of an injury some time earlier on the upper thigh or buttocks.

Bigger than a bruise is a hematoma. That’s a blood blister, venous or arterial bleeding under the skin, and they can be quite large indeed. Big enough and you might be looking at hypovolemic shock.

The important thing about contusions is that they indicate the body’s received a trauma. Think about what structures are under the point of impact. Kidney? Spleen? Liver? They give you an idea of what more to look for.

A puncture wound is deeper than it’s wide. What’s injured could be anything anywhere in a cone-shaped section starting at the puncture site and extending the length of whatever object caused the puncture. Control bleeding with direct pressure, and treat for shock.

Special cases of puncture wounds include sucking chest wounds. That’s where there’s an opening to the outside air through the wall of the chest. When the patient breathes, rather than having air come in through the nose and mouth then into the lungs, the air enters the side of the chest. How to treat it: With an occlusive (that is to say, air tight) dressing. Petroleum jelly on gauze works. Glad Wrap works. The wrapper that a roll of gauze comes in works. The patient’s driver’s license works. Use what you have. Tape it down on three sides to provide a flutter valve to allow air out but not in. (While some sucking chest wounds bubble, not all of them do. Assume any chest wound is a sucking wound until proved otherwise.) Not all chest wounds are obviously chest wounds. Depending on exactly what point of the respiratory cycle the patient was in when the injury occurred, that is, where the diaphragm was, what looks like an abdominal wound might be a chest wound. (Conversely, what looks like a chest wound might be an abdominal wound.) You won’t do wrong by putting on an occlusive dressing.

Another place, less well known, where you want to put an occlusive dressing is the sucking neck wound. If one of the large veins is severed (external jugular, for example), the pumping action of the heart may draw air into the vein, down to the heart, up to the lungs, and there you have an air embolism. Which is not good for children or other living things. So for a neck wound, consider putting on an occlusive dressing.

A special case of puncture wounds is the impalement. That’s where the penetrating object is still in place when you get there. What you do: Don’t remove the object. Fix it in place so it won’t wiggle (rolls of gauze on either side, tied down hard, works great). Cut it off short and transport it to the hospital with the patient. The reason you don’t remove the object is because doing so might do more damage as it comes out, or it might be tamponading an artery which, once the pressure is released, would start bleeding internally at a place you couldn’t reach for manual direct pressure.

If you have bleeding around an impaled object put direct pressure beside the object, not on the object itself.

When might you remove an impaled object? If it’s obstructing the airway (airway trumps everything). If the scene is unsafe (rising water, approaching fire) and if you don’t move the patient right now he will die. Or if the impaling object is otherwise a major life threat just by existing (for example, you’re in a wilderness situation (more than a mile to the nearest road, more than an hour to the nearest hospital), it’s forty below, and the patient is impaled on an ice axe. Leaving it in place will guarantee that the patient will die of hypothermia as the ice axe radiates heat from his core. So consult your conscience, make your best choice. and roll the dice.

For gunshot wounds the primary problem facing you is bleeding. Here is one of the few times that you’ll be looking at circulation even before you look at airway. You won’t ignore airway, and after your first sweep you’ll be back at Airway, Breathing, Circulation just like always, but the first thing that’ll kill your gunshot patient is bleeding.

For anything other than a through-and-through wound to an extremity assume that any gunshot also hit the spine and take full spinal precautions.

With gunshot wounds you need to pay especial care to scene safety. Is the shooter still around? This includes suicides. Just because the guy’s lying there very still and is covered with blood doesn’t mean that he isn’t awake, aware, and planning to kill you with that pistol he has clutched in his hand. (One of my cop friends has a funny story about that. There’s a suicide in a bathtub. The cops come. The photographers come and go. The crime scene guys come and go. The guys from the coroner’s office show up with a body bag, and one of them reaches out to take the pistol out of the dead man’s hand, and the dead guy says, “Don’t touch the gun.” They call the EMTs…. And there’s an adage that even a dead guy can kill you with a shotgun.)

What else? How about evisceration (aka “guts hanging out”)? What you do for that is: a) don’t try to put ‘em back, b) apply a moist dressing, c) put an occlusive dressing over that. Treat for shock. It’s sometimes helpful to have the patient bend his knees (less pressure on the abdomen), and you should work to keep him calm; crying and screaming increases abdominal pressure and can make the organs protrude more.

Traumatic asphyxia: Blunt trauma to the chest reduces venous return to the heart. The patient’s face takes on the blue color that you expect with strangulation. You even get the pinpoint hemorrhages in the eyes that you expect with strangulation. The neck veins protrude. But what do you do about it? High volume oxygen. ABCs. Treat for shock. Suspect other chest injuries including cardiac rupture, aortic dissection, and pneumothorax (paper bag syndrome).

There’s lots more I could talk about — trauma is a major field of study and you could easily fill a thousand pages with just information on trauma to the chest.

Burns are an entire field of study (which I’ve already touched on lightly). First, stop the burning process. Usually that involves copious quantities of water. Next, remove watches, rings, or other things that might form tourniquets as the tissue swells. If you find pulses, mark each spot with your Sharpie marker, because later on someone will want to know where you found them, and they may no longer be available due to swelling. Then dress the injured area with loose, sterile dressings. If the hands are burned keep the fingers separated. Don’t allow skin-to-skin contact.

Frostbite: Treat as a burn.

Abrasions (AKA “road rash”): Treat as a burn.

For any trauma at all: Keep yourself safe. Call for help. Make the scene safe. Then airway, breathing, circulation, shock.

If you do it right in the first five minutes you can make a big difference in the ultimate outcome. The act of staying safe personally is the minimum definition of “doing it right.”

Oh god. I can't even look at the word "degloving" without freaking out. I adore these medical posts and reread them fairly frequently, but I'm going to have some trouble eating dinner tonight. Evisceration? No problem. But show me the "d" word and I curl up into a ball and whimper.

That bit about drug overdoses leading to crush injuries is fascinating. It never occurred to me that passing out on your arm could do that much damage, but of course it ought to be obvious. I fall asleep on my arm all too often, but I invariably wake up sometime shortly after it's gone completely numb. Feeling returns (painfully) quickly. I suppose I just never thought about what would happen if I couldn't wake up.

I'm reading that more as "wash off with clean water or similar disinfectant liquid" than "wipe" only because with anything squishy the last thing you want to do is wipe dirt into it, whereas rinsing with drinking-quality water or similar would stand you a good chance of getting more crap out of the wound than you're putting back into it.

An exception might be if you have some of those alcohol wipes and the injury isn't very deep, then you could wipe it clean I suppose.

(For some literary reason I'm thinking "cheap rotgut whisk(e)y" falls into the category of "similar disinfectant liquids" - it sure as hell isn't a beverage, but you might have it around if you were two weeks out from civilization...)

The U.S Mine Safety and Health Administration has a first aid book that includes traumatic amputations, object-embedded-in-eye, etc. It's quite reasonably priced. (In searching for the book I also discovered that MSHA has an annual rescue contest! Bet that's fun.)

Suzanne @ #1, paralysis of the arm due to nerve damage from that sort of fell-asleep-on-it crush injury is called "Saturday night palsy". "Drunkard's palsy" is an older name. You can also get "crutch palsy" if you use crutches incorrectly (damage to the axillary nerve in the armpit).

I'm scheduled to attend an EMS class at work in a month or so, but I doubt they'll go into as much depth as Jim's posts on here. It's only six hours long.

I grew up on a working farm and can honestly say the worst injury any of us ever had was when my older brother jammed a piece of 1/4" rebar up inside his big toe. Bush-hogs, hay balers, tractors, sickle bar mowers, etc, we had a healthy respect for and kept our extremities away from them.

Suppose the patient is freaking out from pain, fear, confusion, and they're preventing us the lay-responders from treating them or they're risking exacerbating their injuries or they're risking compromising the treatment we've already begun. What do we do to calm/control the patient?

This is one of the posts I had to stop looking at partway through, to avoid getting dizzy and passing out. Thinking about certain kinds of injuries can do that to me, especially anything involving internal bleeding. Glancing quickly back up, I see that one of the firefighters Mr. Macdonald was training had the same reaction, so maybe I don't lose all macho points.

The first and most important thing to do is control yourself. Speak slowly and calmly; move in a slow and deliberate manner. Stay where the patient can see you. Hold his hand. Tell the patient what you're going to do before you do it. Be honest, especially about whether something you're going to do will hurt.

Play the Medical Professional in the movie in your mind and let your belief in yourself wash over everyone around you.

When might you remove an impaled object? [...] If the scene is unsafe (rising water, approaching fire)

Or, of course, approaching Godzilla rip-off.

And a note on passing out / squeamishness: I've always had a sick fascination with finding out how *I* would react in a situation like that. I mean, of course I wouldn't want a fellow human being to be horribly mutilated in front of me just so I can find out if I'll keep my lunch, but... I'd still like to know if I would. Closest I came was during my time working as a nurse's assistant when a patient who's had some kind of surgery on an artery in his leg (I believe they took a bit of that artery and used it for something somewhere else in him) (could it have been a shunt?) had said artery burst open for some reason. Someone called for me and told me rather quietly to go and fetch certain things, and when I brought them into the room there was a bit of high velocity blood, but the only thing I felt was completely calm and focused. I brought them the things they asked for and helped manoeuvre the bed out of the room as they rushed the patient back into surgery. Afterward I did feel a little light-headed and jelly-legged, but that passed quickly. The whole incident did little to satisfy my curiosity on how I'd really react to something shocking.

Uhm. Sorry for going off-topic there. Once again a great medical post. I really enjoy reading these. Making Light: Come for the Literature Scams, stay for the Traumatic Amputations!

Gah. Sometimes I can't believe that I actually read these posts. Well, I've been in enough situations to know that I'm going to react okay— but my imagination is always worse.

Farms are sources of dangerous accidents. Strangely enough, so are college art departments. I had a professor who told some fairly grisly stories of students who deliberately defeated safety mechanisms on art equipment (such as a motorized press) and the results. This was, in my case, given in the safety lecture for use of the clay mixing machine.

What does a clay mixer look like? Imagine the blade of a Kitchen Aid stand mixer on steroids. Turn it on its side and sharpen it. Put a nice trough around it— but enable it to be turned on while the trough is on its side because sometimes that's the only way to get the mixed clay out. Then imagine what would happen if your arm got caught...

Dr. Giebar was very good at painting the picture. Nobody got hurt the entire time I was in college.

Jim, I learned that when using direct pressure, only the *bottom* cloth has to stay on, you can swap out the upper cloth as it gets soaked. But it's been a while since I was taught -- has that changed?

As to contusions, I have a lot of them right now (hacked at ivy through a ground-level balcony railing while sitting in a chair) and I expect they'll be like all my others -- they stay purple. They get lighter and lighter purple before they go away, but never greenish or yellow.

Lila @6: Now that you say it that way, it sounds familiar. I think I've heard the of Drunkard's palsy before, but I don't think I ever knew what it meant. Thanks for that. Crutch palsy I've nearly encountered in person, though no one called it that at the time, when an injured friend started having some trouble with tingling in one of his hands. I believe it eventually cleared up. I don't think he was using the crutches for very long. I just remember him worrying that he'd done something terrible to his spine.

At a shop I worked in once, someone brought in a copy of a pic showing why machinists don't wear rings at work. Think partial one-digit degloving. Was I ever glad that image was in black and white!
As to reactions by this spectator, it varies. I haven't had shock-type reactions of any sort to the various accidents I've witnessed, but these weren't real serious ones--though they easily could have been. When I pass out is usually when the sharp instruments have been used on *me* for a while and I'm conscious (and possibly hyperventilating.)

re amputations/gross trauma to the extremities: The Army is now teaching that tourniquetting the limb is the way to go. The thinking is that one has 6 hours to get the patient into surgery, and blood loss, seepage, etc, are more risk than the potential loss of the extremitie.

Ah, soft tissue amputation. Well I remember the days when people didn't tell me, "Gosh, I would never have known if you didn't hold your thumbs up side by side!"

I had the pad of my thumb nipped neatly off by the hinge-edge of a slammed door (in a psych unit, as I was one-to-one-ing the homicidal sixteen-year-old who truly, despite having attacked many of her peers and counselors, clearly had no intention of removing any of my body-parts that day) and have no idea how much it would have bled on its own because before I knew what was happening, I had clamped my thumb in the fist of the same hand and was squeezing as tightly as I could. I didn't even know I was missing anything until the door opened again and a small, soft, oval, beige object fell to the floor. "That's my thumb," I said calmly.

The nurses bundled me down the hall as other staff took up position to watch the homicidal sixteen-year-old who was facing away from the door and saying in a monotone, "I didn't mean to. I didn't mean to." I was calling back over my shoulder, "Could someone get the bit of my thumb that came off, and wrap it and put it on ice?" I think they thought I was in shock, but I'm usually like that in a crisis.

(I asked the nurses politely if they could please call my staffing agency and let them know what had happened. When the on-call person called back and got them to let her speak with me, she said, "Oh my GOD!!! Are you all RIGHT!!?!" and I said carefully, "Well, that depends on what you mean by all right." She was still telling that story months later.)

(Oh, and speaking of compression? A piece of tissue amputated by being squeezed off in a door is not, in fact, reattachable, or mine wasn't. I was very persistent about getting it to the hospital with me, but it turned out there wasn't a hope. On the other hand, no one seemed to want to take responsibility for throwing the severed tissue away, even after I'd had the skin graft surgery instead, and it sat in a tub on my hospital room windowsill for two more days.)

Later, when the (marvelous) EMTs arrived, one of them knelt down next to me and said, "Could you open your fist so I can see the injury?" And I discovered in myself a great reluctance. I said distantly, "I'd really rather not."

It didn't actually start bleeding freely until 45 minutes or an hour later, in the ER, I think, when the very serious young surgeon on duty was explaining to me that if it were any other finger, they would nip back the bone until they had enough skin to sew over it, but, he said apologetically, "Not to make a bad joke out of it, but with thumbs, length really does matter."

Ah, how it all comes back. If this were Livejournal, I could use my hand x-ray icon which says "Thumbthing Wicked." My friends did not stop making thumb jokes for months.

Marilee @ #18, it was 10 years ago (gosh - I hadn't realized that). Yeah, fiberglass, I think. I remember the joy of getting the thing off so I could shower instead of sponge bathe. That implies plaster.

Thank you for these posts. You've just reached the subject I want to learn about most. I was unlucky enough to be on the scene for a partial amputation, a guy rolled a golf cart onto his friend's ankle and all but severed his foot. Nothing in any of my high school first aid classes prepared me for this. So I did Mom things, which are remarkably similar to your abc's. And then I looked at his foot. Ew! It was bleeding much less than I expected, probably because of the constriction you mentioned. Someone brought a pillow from a nearby house and I elevated the foot to make the man more comfortable. But I didn't apply pressure. I didn't have anything clean. I was out on a bike ride during a camping trip and had no first aid kit. The nearby houses were vacation rentals with no washing machines. The man hadn't lost a cup of blood. I was more worried about contamination than bloodloss and I knew the EMT's were on the way. But I've always wondered if I did the right thing.

Lila #6: I gave myself what I suppose could be called "coupon cutter's palsy" when I finally faced the huge bagful of box tops my late mother-in-law had left. Cutting out hundreds of Betty Crocker points numbed my thumb and forefinger. Eerie feeling.

Back in my Army training days, the recommendation for an occlusive dressing for a sucking chest wound, in the absence of a genuine medical dressing, was to use the cellophane wrapper off a pack of cigarettes.

That was thirty-six years ago; I have my doubts it's still a recommended substitute. For one, fewer people smoke, hence there would be fewer wrappers available. Also -- being a non-smoker, I haven't really paid attention -- it's my peripheral impression that a lot of cigarette packs don't have cellophane wrappers anymore; I may be mistaken.

= = = = =

Calluna V @ #22:(I asked the nurses politely if they could please call my staffing agency and let them know what had happened. When the on-call person called back and got them to let her speak with me, she said, "Oh my GOD!!! Are you all RIGHT!!?!" and I said carefully, "Well, that depends on what you mean by all right." She was still telling that story months later.)

Back about 1982, I took a header over the handlebars of a postal bicycle and split my forehead open on the concrete sidewalk (13 stitches).

So I roll over and I'm laying there on the sidewalk with blood coming out vigorously, with half my face sheeted with blood and one eyeball being flooded with a puddle of it. And one of the neighborhood residents who'd seen the accident comes running up, looks at my blood-covered face, and asks:

"Are you all right?"

Being a polite kind of guy, I answered, "Not bad, considering."

Looking back at that accident, it's clear to me now that the large forehead cut actually came, not from the sidewalk, but from the edge of the inside band of the mesh sun-helmet I was wearing. If I hadn't been wearing that helmet, it wouldn't have taken a lot of the impact's energy, and I'd have smacked directly head-to-concrete, almost certainly with a skull fracture and possible a brain injury. So it really was not bad, considering.

(So, hey, kids, always wear your bicycle helmet, even if it makes you look like a dorky mailman.)

There was a case of a traumatic amputation in Oregon last weekend - a surfer got run over by a fishing dory, and his arm was cut off. He was very lucky in that the surfers out with him responded promptly, got his arm, and got him to shore...and there was an ER doc on the beach. Not a lot of medical details have been released, but here's a description from the doctor's perspective.

I know you love your wedding rings/anniversary bands --- but please, please for the love of your fingers take them off before engaging in any mechanical work or work requiring heavy lifting (horse handling, martial arts practice, weight lifting etc).

I have unfortunately seen way too many of these types of injuries from the days of Ye Olde Nuclear Sub.

The second largest safety consideration is removing necklaces, neckties and any other danglies before working around rotating equipment. Often, I've seen people lucky enough to just have a necktie or necklace ripped off --- but most of the time it doesn't and the instinctive reaction is to put your hands into the machine/device to brace yourself or stop the rotating elements.

A note on cleaning debris/contamination: it is best to just run cool water or .9% saline (if either available) over the wound in a low pressure applicator (8-14 psi --- basically if it exceeds the force of water coming out of your faucet/tap don't use it) for 5 minutes (or as required) prior to dressing.

If you're not an immediate responder, or the wound is older but showing signs of infection (primarily smell; next redness, swelling, goo) irrigate long enough to cause sloughing of exudate before redressing.

...also folks, never apply a turniqute to prevent bleeding from a gushing head wound. *ahem* You laugh. I've seen it attempted.

I remember from shop class in high school, the teacher was very, very strict with jewelry wearing. He had seen a couple of deglovings, and never ever wanted to see one again...he had pictures. We never wore any jewelry.

Mr. Macdonald, I just wanted to say thank you for your contributions. They're perhaps the most useful things I've ever gotten off the Internet.
I appreciate it, sir.

The fly larvae that inhabit open wounds don't all dine exclusively on dead tissue. Some of them like fresh meat, too. You'll get debridement regardless, but the patient may not be happy about it (ow!).

What this implies is that if a pile of bricks has fallen on my victim, I shouldn't move the bricks unless there's an overriding reason (ABCs, more bricks on the way, etc) -- it's better if the pros are there with the saline before the unpiling happens. It also implies that, if a tree falls in the woods and lands on someone in my hiking party, I should error on the side of leaving the person pinned (again, with the caveat that ABCs are primary, hypothermia is bad, etc) until the pros turn up. Most annoying of all, it implies that when I walk into a room and find a collapsed, comatose person compressing one of their own limbs, I need to be concerned that decompressing that limb could trigger a problem. Is this correct?

Is "tea or cola-colored urine" the only observable danger sign of potential crush injury?

Is time a factor? If a person's leg gets trapped under the bricks and we immediately unpile the bricks and reperfuse the leg, is that better than it would be if we unpiled them two hours later? Or worse? Or no different?

Is time a factor? If a person's leg gets trapped under the bricks and we immediately unpile the bricks and reperfuse the leg, is that better than it would be if we unpiled them two hours later? Or worse? Or no different?

ISTR, and you really shouldn't use this as a guide to anything - it was a while ago, that the figure of 45 minutes was considered the limit before you should leave'em there and wait for the experts, rather than using that crane you just happened to have handy.

I read this post shortly before bedtime last night. And promptly dreamed that I thought I had put a golfball* in my pocket, and when I reached in to take it out, I took out an avulsed eyeball instead. Well, except it wasn't attached to anything, so it technically wasn't avulsed anymore, but I actually saw the word flashing next to the eyeball.

My reaction to information like this is similar to Clifton Royston's @12, and I've fainted at the sight of blood/trauma (my own and others') several times. Makes me so damn mad. My mind starts going into full coping mode, and then my sympathetic (?) nervous system just takes over. Meh.

Me speaking on the 'phone to my stepmother (a GP/family doctor) after I'd been hit on the heat by a large chunk of wood thrown over a roof: "I'm fine, but could you stop by the hospital on your way home and pick up a suture kit to sew up the three-inch gash in my scalp..."

Clifton Royston @ 12 -- yeah, I had the same reaction. I'm not usually that squeamish but this, wow.

I've found that I'm okay if I'm doing something, not just observing (not that I've dealt with many soft-tissue injuries, but extrapolating from other times I've dealt with blood). If I'm just observing then I have time for empathy to take over, and I start imagining myself in that situation and then I pass out. If I'm doing something then I can get mentally involved in that, and turn off the empathy.

Empathy is in general a good thing in interpersonal situations. Ordinarily it's good to be able to mentally put yourself in another person's place. But there are situations in which you absolutely have to turn it off so that you can be of some use, rather than just throwing up and passing out.

Caroline: Yep. The thinking about it gets my guts all wobbly. I recently took a first aid course (Combat Livesaver), in which one of the requirements was to do an IV stick. I wasn't worried about getting stuck (though I dislike it) but about the thought of sticking.

Surprisingly, when it came time for me to do the stick, it was trvially easy (for strange values of trivial) in that I didn't do any of the things I was afraid I would do incorrectly.

But planning to do it, thinking through it before I had the catheter in hand... that was knee-weakening.

Terry: Exactly. It's the thinking, not the reality of a situation, that gets me. I've never been dizzy or weakened either when I was injured or helping someone else, not that I've ever dealt with any extreme situations.

(1) Veins do have muscle layers, but they are puny in comparison to arterial muscles. Veins are generally collapsible, whereas arteries keep their shape. It is much easier to rip through the wall of a vein than an artery, and much harder to close that tear. [I did some vascular surgeries for a year, in my fellowship, and I had nightmares about the surgeries.] While arteries can clamp themselves off, and the smaller ones do tend to remain sealed in traumatic situations, the veins do not seal themselves in such helpful manner.

Linkmeister @ 15: Now you know: veterinarians are the hidden gems in our lives. ;-) We're licensed to practice medicine, perform surgery, and prescribe medication for more than 900 species -- except humans.

Traumatic amputations in veterinary medicine can actually be minor, depending on the species. I once had an emergency call where two students brought their pet in for a traumatic amputation. It was a lizard. He'd dropped his tail, which they thoughtfully carried in too. I didn't charge them the $50 fee and sent them home with their tailless but completely healthy lizard.

Degloving can happen very easily in a lot of species, especially at the tip of the tail. Don't grab anyone's tail, or you'll see a degloving injury. Car vs dog (or other species) can cause degloving injuries of the extremities. Like burns, they take a long time to heal and can lead to scarring.

There was only one time in private practice when I was feeling woozy, and the current episode of "Untold Stories from the ER" just reminded me: a patient came in with maggots all over his leg, which is something even ER doctors don't see very often. I've seen maggots in wounds before, but this one case just left me cold, and for years after I would react to even the thought of this patient. It was a husky-type dog, with a thick coat of fur over his shoulders, and he'd had a small bite wound in the skin. It couldn't be seen through all the hair, but the flies found it and the maggots were inside under the skin, looking like a bowl of soup. Once the maggots were outside the skin, I could handle them, but looking into the wound left me feeling faint.

Crush injuries: the initial damage comes from the trauma to the muscle, which releases myoglobin. Myoglobin is a toxin, and damages the kidneys. It isn't an instantaneous toxin, though, so you do have time to transport your patient to the hospital. If the extraction is going to take time, that's when you start the IVs in the field -- start an IV as soon as you can in any case. If you're the first person on the scene, try to get your patient out of the crush as fast as you can, paying attention to the ABCs throughout.

Note: Everything Mr. Macdonald has posted about human patients also applies to other species. Communication with nonhuman species may be difficult, particularly in a frightened patient, so you may need someone else to control them. Blindfolds help calm a lot of species.

Eye injuries always make people wince, but there's more chance to save eyesight than you might think -- even an avulsed eye can retain sight, as long as the optic nerve isn't too damaged.

Ginger @ #49, I want you to know that when I wrote that comment and linked to my original post I thought of you. He's pricey as hell working on Tigger, and every single thing he does is billed, but he knew what to do that night.

Reading this, I am grateful for never having taken up extreme sports, though even such indoor and feminine activities as sewing can be dangerous -- I once impaled one of my toes with a sewing needle. I was barefoot, it had lodged in a shag carpet, and I didn't see it until I stepped on it. The needle came out through the top of the toenail about an inch. Since I was about twelve at the time, I didn't have the fortitude to let my parents pull it out (it was stuck very firmly in the nail) and we went to the hospital.

It put me (and my parents) off body piercings when such things came in.

Linkmeister @ 50: Good for him. I haven't saved anybody's life, and I've seen two different incidents in public where someone needed medical assistance -- but I could see that the person was stable and that help was on the way, so I didn't intrude. No sense butting in where I'm not needed.

In veterinary medicine, the successful client-patient-vet relationship is based on rapport -- if you don't get along with a vet, find another one. Most of us really wanted to be vets, and really like what we do, so it boils down to the minor personality differences. When you find a vet you like, you'll find his fees tolerable. Also, it's good that he sets his fees high and bills everything. We tend to be a bit softhearted, as a profession, and don't charge the fees we really should be. ;-)

Terry@ 51: We're not all perfect..ok, we're not perfect, but many of us do develop the skill of rapid assessment without relying on verbal history. We tend to be the kind of people who make rapid decisions as well, so if we make the wrong initial assessment, it can go badly instead. Experience counts for a lot, which is why we need hands-on training in school as well as after graduation. Medical doctors need it too, which is the basis for the residency programs; ours are still mainly optional or for specific programs, but all newly-minted graduates get OJT in their first years of practice.

#13: I've not, thankfully, had to deal with anything anywhere near this dire. I have found that in far, far less dire situations, I can sometimes Be Calm when someone else is freaking out, as when a friend driving us home wound up on a narrow overhang on the 59th Street Bridge in Manhattan. She dealt by saying over and over, "Why is this here? Why are we here? I don't like this!" I dealt by saying, "You're doing fine. It's going to be all right" and making generally soothing noises.

I don't know if my soothing noises helped her, but they helped me by giving me something to focus on other than the fact that I was in a car in a narrow overhang with a very scared driver. We all survived, and we all agreed not to do that ever again.

Going even more off topic: After chatting about various types of ebola at a party with Seanan McGuire, I asked how long before the disease resistant bacteria become a serious hazard. I've seen that hospitals, restaurants, and probably a lot of hotels have the bacteria killing soap that Jim talked about back when he explained how to wash one's hands.

Seanan cheerfully explained that various health organizations figure we've got somewhere between 8 and 13 years before disease resistant flesh eating bacteria starts wiping out entire classrooms of kids, especially if they don't wear the kind of foot gear you can take into school showers. Then, she explained how the high price of gas combined with the economics of being a migrant laborer would make or is already making salmonella and, I think, cholera more likely. (If I am getting the specifics wrong, blame my listening skills.)

I kind of have to take these medical posts in easy stages and read what I stand to read. I get all squingy inside.

If anyone is about to explain to me how Seanan's information is incorrect, well, I really rather hope it is.

Degloving injuries freak me out to the point that I never wear rings at all.

I'm extremely grateful to the universe that I've had to face very few traumatic emergencies. But oddly enough, I'm better taking care of others than I am taking care of my own injuries. I once sliced the heel of my hand with a box-cutter at work. It bled, but I could see it was superficial and guessed, correctly, that it would only need a butterfly bandage. And still, I got woozy and light-headed and very nearly barfed.

I once worked on a legal case in which the plaintiff suffered a horrendous injury. She was delivering newspapers early one morning, tripped on an apartment building step, and hurtled head first through the old-style glass front door. (Turns out the building code didn't actually require safety glass to be installed unless the door was being upgraded or replaced or remodeled. But you have to be pretty dim-witted not to voluntarily upgrade the doorway glass.)

I guess the injury was more of an incision than a laceration, although laceration is what we called it. It started on her left cheekbone, traversed her face via the bridge of her nose, across to the other cheekbone, and down her jaw. Her eyes were undamaged. She recalled seeing the inside of her own face. (Luckily she and her husband worked together, so he was right there.)

She was fortunate enough to be seen by one of the very best plastic surgeons in the area. I do not know how she's doing now, in terms of scarring or nerve damage or PTSD, but the early results looked remarkably good. (PS: she did win a settlement which was more or less adequate but hardly a jackpot.)

Larkspur@56 The human body can be amazingly strong --- and freakishly weak. Like you, I've seen it in the freakishly weak state enough to add extra caution to a lot of physical activities, or just avoid them entirely.

larkspur@ 56: Laceration is caused by blunt trauma, so the slash wound on her face was probably should have been labeled a "slash" or an incision -- but this is something that I learned as a fellow in a comparative pathology department. It might be argued that the trauma was initially a blunt (i.e., the flat pane of glass) as well as a sharp trauma.

Lacerations can be amazingly sharp-looking. I got one on my knee when I crashed a scooter. It took five sutures -- and no, I wasn't allowed to put them in myself.

I've managed to remove both my eyebrows before the 6th grade, both times at school. Once was in the first grade, the other one in the 5th. Both times my mom came and got me, put ice on the injuries and left it at that.

My wife stepped on a sewing needle with her bare foot several years ago, but she stepped on the eyelet end, ramming it up into the heel of her foot. She couldn't reach it easily, so I got some pliers to pull it out, but every time I tried, her involuntary hissing of air between her teeth in anticipation of pain so upset me I couldn't do it.

I was holding her foot down so tightly, though, that it went to sleep, and when she realized that she just reached down and jerked it out herself. By the time we got to the doctor's office for the inevitable tetanus shot, he couldn't even find where the needle had been...

J.K.Richard@57Larkspur@56 The human body can be amazingly strong --- and freakishly weak. Like you, I've seen it in the freakishly weak state enough to add extra caution to a lot of physical activities, or just avoid them entirely.

It's not the expected things that get you, though. I tried to catch a ceramic bowl before it hit the floor last night, jammed a finger straight on into the counter... and although the finger's a tad sore, I've been in screaming pain from right wrist through to slightly behind/above my right ear since[0].

Interestingly enough, the Methocarbamol/Ibuprofen combination (Robax platinum) seems to help -- Ibuprofen alone doesn't quite get there -- but even in combination with the pseudoephedrine that's making allergy season tolerable, I'm left spectacularly drowsy.

[0] This doubtless due to aggravating the annoying neck/shoulder injury that's been sluggishly healing for a bit over a year...

I don't want to look at the pictures because I have a good structural visual imagination when it comes to injuries. It's like my objection to the driver safety horrorshow movies we were shown in high school: I already take the subject seriously. I don't need a case of the shakes on top of it.

B. Durbin (16): they took the safety mechanisms off a pugmill? Were they insane? (My own description: a clay mixer/pug mill is a heavy-gauge scaled-up meat grinder that can chew up adobe bricks.) I'm not going to say "just as well," because I'm sure it was an awful injury; but people who don't pay attention to safety don't belong in pottery studios.

Printshops are another bad place for that. The first industrial-strength paper cutter I ever met was designed to require two-handed operation, using controls located on opposite sides of the machine. This was intended to make it impossible to get your hands anywhere near the cutter itself. The owner of the shop had rigged a foot treadle out of scrap lumber and rope so that he could push on and straighten up the paper while it was being cut.

Clifton 12: You and me both, my brother, you and me both. I keep going back to it though, and finally finished it just now. I figured if I could have saved someone if I read this, and not if I didn't, what's a little dizziness and nausea compared to someone's life?

James 13: This is what we call magic. Just so you know. Maybe you already did.

Angiportus 20: Is your posting name a Catullus reference?

Jenny 25: I've had "Drum Tuner's Palsy."

James 43: I've definitely got a case of avulsion revulsion.

Caroline 44: I think you've put your finger on it exactly. I don't throw up or pass out; I freeze up, but the net result is the same: uselessness.

sara 53: Shag carpets are a menace, aren't they? I had a young friend cut his foot on a piece of broken glass embedded in one...his mother had broken a picture in her room, missed a piece of glass, and sent him in there to fetch something.

I mostly know how I'd react with Big Trauma around. Unfortunately it's go into a mild shock. So I'm less than helpful.

I discovered that several years ago during a week long horse trek I was on. We were sleeping in a hut and a guy jumped from an upper bunk bed but landed with his big toe on the corner of a stool and the force split his toe open. Would that be a laceration?

Fortunately one of people on the horse trek with us was a nurse and she had a first aid kit complete with stitching equipment etc. on hand. Since it would otherwise have taken hours for the guy to get medical help. I was the only one there right then and there so I got recruited into helping her out.

Nothing big just passing gauze over and throwing things in the trash that she handed to me etc. I started to feel really woozy and my stomach turned and when I was sure I was going to throw up and I had black spots dancing in front of my eyes I said I had to go out, and NOW. She didn't want to let me leave, she needed the help and had her hands full but I dropped everything and didn't even say anything to her and stumbled out terrified I'd throw up over her and the guys toe (now that would be healthy).

It took me several tries to get my boots on because I was shaking but I wandered out of the hut and towards the outside toilet in a small wooden shed, very close to fainting but keeping going with the single minded motivation that if I was going to throw up it was going to be into the toilet. I managed not to collapse or fall down. Once I got there I ended up just sitting in the shed for I don't know how long until the black spots stopped dancing and I felt better.

I'm just really glad I didn't head out in a random direction as confused as I was since it was in the middle of the night and we were completely in the middle of nowhere, in a very remote place most easily accessible on horseback.

Anyway yeah, that incident sort of dashed all my hopes of being helpful when Bad Things had happened to someone around me. How common is that sort of reaction and what's the best way of trying to deal with it?

This seems a good place to mention that I think one of the limits on personal freedom for adults should be that they don't have a right to refuse medical attention immediately after an accident. Between shock and adrenaline, people can't make sensible decisions in those circumstances.

My friend was t-boned last week by a dumbass who ran a stop sign while talking on a handheld cellphone. He was wearing a seatbelt, so he was saying "this sucks" instead of just lying there. He texted me to say he was OK but just really pissed off (his car was pretty much wrecked). He went home.

That evening, he started to vomit blood, and went to the ER. Turned out he'd had a broken rib, and it punctured his lung (I guess he was coughing blood and swallowing it). He had surgery to fix his lung, and he's going to be OK, but it could have been very bad. I think he should have been taken non-optionally to the hospital to be checked out.

Or am I overreacting because I spent about 24 hours this weekend scared out of my mind (between the time he said he was vomiting blood and the time I next heard from him)?

Xopher@66: That's a hard call to make. If the patient presents with no pain and no obvious deficits, how can an EMT crew justify dragging him off to the hospital? I've seen them trying to convince someone in need of treatment -- i.e., diabetics going into insulin shock or similar cases -- and they have to be careful. A good crew will try to get someone who's been in a nasty accident into the hospital for a check, but an awake adult with no obvious injuries is allowed to decline treatment. I'm sure your friend won't make that mistake again, and I'm sure you won't make that one yourself.

I expect it is different in places where the injured person's first thought isn't "I can't afford to go to the hospital this week."

Seriously, I busted my head at work (very minor, a few stitches and a black eye that lasted two weeks) several years ago and tried to decline the ambulance ride to ER until it was pressed upon me by both my boss and the HR lady that it was going to fall under workman's comp and I wouldn't get billed for it. And I was insured at the time (but not sure whether insurance covered ER if you weren't admitted to hospital afterward...)

Thena - second that one. And add 'How will I get home?'
At least my ribs weren't anything like that badly broken. I got away with waiting until the next weekend and having a friend take me to the doctor.

#66: I was in two hit-and-runs where I refused treatment— but they were both fairly low speed, I was strapped in appropriately, and I wasn't even bruised either time. However, if I were bruised or cut, I'd go for the checkup, if only for the tetanus shot. Safer that way.

TNH @#61: The description was "multiple breaks in the arm." He didn't go into much more detail because he didn't have to. And actually, you don't have to remove "safety mechanisms" because you have to have the blade exposed to push the clay out— but if you're sensible, you keep your hands away.

Come to think of it, he may have described that person as and overly helpful friend, not a student. Which makes it slightly different, but still dumb.

The really dumb one he described was a girl who decided that the press which had two separate buttons to operate (at arms' length) was in need of more personal attention, so she rigged it so that she could get a hand free to put in the way of the press. Pressed arm was the result.

Don't turn off safety mechanisms. Or reach past a grille. They're there for a reason.

--No, I'm more into Martial. And I do not like shag carpets either! 1 time I kept tripping over a treacherously hidden phone cord at my coudin's place--there was a hole in the floor that you had to watch out for too. Another time I stepped on a needle (you guessed it, point first) and this after diligent and constant efforts to keep all needles corralled.
Thing is, I didn't have any choice on what sort of carpet this place had when I moved in 21 years back. Better than one place I lived in though--a mixture of small squares of every kind of carpet you could imagine. Somehow I didn't have any accidents there.
My problem in emergencies is as much with sound as sight. I have twice heard a man screaming out of control and both times it rattled me. I've got sensitive ears anyway. Maybe I should start carrying earplugs...

Saw the remnants of a high-speed ATV wreck this weekend when I was visiting my dad. The ATV was in pieces, and blood, hair and vomit was on the tree trunk that stopped said ATV while it was airborne. Said tree was good thirty feet from the road. We apparently just missed the removal of the rider because it was raining an hour before and there was still puddled blood on the ATV.

... Apparently, the guy in the wreck (one of my father's neighbors) survived.

... He also refused transport to the hospital.

The mind boggles, because we figured he was either dead or headed by air-evac to the nearest trauma center. It was That Sort of Wreck.

Thena @68, I was in that situation last week, when I passed out in the bathroom after throwing up all night. I scared the crap out of my boyfriend, whose first thought was that I was having a seizure (as I was apparently moaning while unconscious; he's seen other people have grand mal seizures and that is apparently how they started). I have never had a seizure so if I had been having one, 911 would have been warranted. I was not having a seizure though; I was just terribly dehydrated.

I missed him asking "Are you all right? Are you all right?" and woke up just in time to hear him announce that he was calling 911. I talked him out of it, because I went immediately from unconscious to totaling up how much ambulance + ER would run me. And I have insurance. (He let me talk him out of it only because I was lucid enough to try, which meant I wasn't in immediate mortal danger.)

I was still out nearly $100 from the trip to urgent care; I probably should've tried to hold out another hour and make it to student health, where I wouldn't have a copay.

I hate the way U.S. health care works. That was my first conscious thought.

the only safe power tool, and this applies to all kitchen, craft, etc. tools that might cut, crush or otherwise maim you, is an "off" power tool, preferably with the power cord pulled out of the wall as well.

And any guards, holders, etc. that are provided must be used. Plus be very careful when washing things,

And Caroline, I am so with you. Right now my hubby and I are not covered because I'm not employed and he's works for a small business with four people, they just can't afford it.

Earthquakes, surviving - do NOT get under something heavy, lie down beside it. If you're stuck on a bridge with an overpass above, turn off your car's engine, put it in gear, set the brake, get out and lie down beside it. When things collapse, they'll usually bridge over and you'll be safe in the void.

This was in an email that came through a month or two ago and I've had no luck finding the source. There were a couple other good points, but this is the vivid example that's stayed with me:

xeger, #60, we old tottery folk are taught not to try to catch things. Just step back and let it drop. This is why I don't carry valuable things. It's also why I don't buy much food in glass because I have to have someone else come clean it up.

Xopher, #64, I got rid of the carpet and put in laminate almost exactly a year ago. Not only is my breathing better (although I still need the regular inhalers), but I haven't fallen in the house since.

This thread is tempting me to do a post on some of my stories from working on cattle ranches in northwestern Australia, but I'm not sure if I shouldn't keep them to dribble out slowly. I knew a lot of people with a truly odd disregard of safety - silly behaviour with old oil drums (NO! NO! NOT THE ANGLE GRINDER! IT'S SUICIDE, I TELL YOU!), petrol, explosives, firearms, motor vehicles, arc-welding gear, poison... And managed to injure myself in a number of amusing ways.

Working on our family farm, I managed to step on nails stuck in boards buried in cow manure (that got a quick trip to the doctor for a tetanus shot, for sure), fall off the barn roof (was young and the soil around the barn was soft, so I didn't break anything), various accidents with fishhooks (push on through, do NOT pull out), but never had anything as serious as when I stabbed myself with my father's fillet knife.

While it was still in the sheath. In the bottom of my foot.

The knife penetrated at least an inch into my foot, and bled profusely (especially for a puncture wound). It must have nicked a blood vessel of some sort because it just would not stop bleeding for at least 15 minutes, more than enough time for my mom to dash off to a neighbor's house for more substantial bandages than the usual Band-Aid.

The next day my foot hurt like hell and it was swollen up, but I could walk on it a day or so after that. I've still got the little scar...

Sica @ #65, desensitization may work. They do an amazing program at Georgia Tech using virtual reality for people who are afraid of heights. They start with someone who's scared to stand on a chair, and end with taking them up an exterior glass elevator (first virtually, then in real life). I imagine if this is really important to you, you could find someone to design a program for you (start with drawings, progress to photos, then video, then observe in a clinic...?).

I've never been terribly squeamish, but once I started getting a health-care education it was amazing what I could tolerate because my interest overwhelmed my fear and disgust. (Gross-out-warning!)

Not sure whether it falls into the "potential for palsy" category, but I did find a Google result called "Hand Arm Vibration Syndrome" that describes at least partially what I experienced after a day of using a slide-hammer to remove and replace the wheel bearings on my truck. Reduced grip strength (I'd say it was down 40-60%!), reduced grip closing speed, reduced hand general sensation and some tingling. All this showed up the day afterwards, and didn't fully fade for almost a week. That incident caused me to buy some gel-palmed bicycling gloves for use while driving, as the vibration from the steering wheel had similar but much more short-term effects...

Squeamishness: I haven't been tested much on the gore front. (No, I did NOT watch my wife's Cesarean section...) I was generally OK in the few cadaver labs I've been in, but the live pig lab made me a bit queasy...

As for vomit and other human effluvium, though, becoming a husband and then a father significantly raised my tolerance to the smell/look/etc.

I was once complimented in the ER for my high-school bandaging skills that involved paper towels and duct tape for a tree-fort nail through my foot. Reading this thread suggests that the foot closes up pretty good on its own, though!

#75 Paula Helm Murray: ...preferably with the power cord pulled out of the wall as well.

Ain't no 'preferably' about it. Don't even consider changing the bit in a power drill while it's still plugged in. On a lot of power tools you'll find a little clip on the power line near the handle. That's for clipping the plug-end of the cord to, so you can see it right there, unplugged. (Remove the battery pack from your cordless drills.)

Oh -- snowblowers. When they jam, even if they're shut off, there can be enough tension on the blade that when you clear the jam the blade will rotate a couple of times. Do not stick your hand into a snowblower.

Electronic equipment that has capacitors in the circuitry is still powered even if it's unplugged from the wall.

Let's not even talk about firearms. Even if it's unloaded and you just checked for yourself, it's still loaded. Be careful.

That's what always gets me when I read about people involved in firearm mishaps, equipment accidents, whatever; did they not have someone around when they were growing up pointing out how to respect these devices? My dad --always-- explained how to --properly-- use whatever machine we were working with, and told us repeatedly not to EVER think that a firearm was unloaded.

I've described my table saw as a very demanding mistress; if I treat her with care and understanding we can do some great things together, but if my attention wanders away from her for a split second when I'm with her, she will mess me up BAD.

So far I've been careful; the worst that's happened is when a 1.5" cube of pine got caught between the blade and guide and fired at me at high speed. Bounced off my chest and made a hell of a bruise, but nothing more.

If that's the worst mishap I get with it, though, I'll consider myself fortunate.

John T. Thompson (inventor of the Thompson Submachine Gun) would not allow a piece of bar stock that would someday be milled into a barrel to point at a human body.

The guy I mentioned in the main post who had the degloving injury on a running lawnmower had managed to keep it running by putting a pair of Visegrips on the deadman switch on the handle.

Speaking of lawnmowers, when you're going to work on them in any way that involves the blade, not only should you have it shut off, you should unclip the sparkplug wire. All it has to do is kick over once with your hand in the way....

Marilee @77xeger, #60, we old tottery folk are taught not to try to catch things. Just step back and let it drop. This is why I don't carry valuable things. It's also why I don't buy much food in glass because I have to have someone else come clean it up.

I've gotten much, much better about such things over time -- these days, if it's heavy or sharp, it's welcome to make a dent/cut somewhere other than me. I think what got me this time was the usual "almost got it" problem :(

John L @ 83That's what always gets me when I read about people involved in firearm mishaps, equipment accidents, whatever; did they not have someone around when they were growing up pointing out how to respect these devices? My dad --always-- explained how to --properly-- use whatever machine we were working with, and told us repeatedly not to EVER think that a firearm was unloaded.

Veering briefly aside into a totally different argument, one of the good things[0] about requiring a license to hunt/purchase firearms is the -requirement- for the successful completion of a firearms safety course. For folks that have grown up with firearms safety, it's a no-brainer, and a decent refresher... for those that haven't, it at least exposes them to ideas like "treat all firearms like they're loaded".

[0] ... and let's not go past this point into discussing firearms, possession of, usage of, yada, yada... that's a different (endless) thread.

My father has a friend who's missing most of the fingers on one hand. He was using a rotary hand saw to cut firewood and had taken the guard off. When the saw kicked back on a knot, his hand ended up in the blade.

... Apparently he waved with the remnants of his hand at every passing car on the way down to the Phoenix, too.

It sometimes works the other way as well. My sister-in-law is an EMT. She used to keep her horse on a farm, so when one of the farm workers ran over his dog's front paws with a tractor and all the pads were split (lacerated) and bleeding like crazy, she grabbed the dog and pressure-bandaged the feet (which stopped it bleeding out on the way to the veterinary surgery). Then she sorted out the owner's bitten arm.

Ginger, as a practicing small animal veterinarian (I'm out of touch), do you want to add anything about blood loss from cut/lacerated pads?

Even if it's unloaded and you just checked for yourself, it's still loaded.

That goes for dart-guns as well. I've given a lecture to young veterinarians about darting (remote injection) several times. Half of it (at least) is on safety. I've had the experience of "knowing" the blowpipe was empty, swinging it around above my lightly-shod foot while carrying it back the car (bad habit), then checking one last time (good habit) and finding there was still a loaded, pressurised dart in there, containing anaesthetic drugs. There's a very high potential for doing serious damage to yourself (or bystanders) with some of the more potent narcotic agents used in wild animal anaesthesia.

My speciality is lab animal medicine, but I've been in private (small animal) practice, so I'd add a few things.

First stop the bleeding as mentioned, and take your dog to the vet. Blood loss can be dramatic from a foot pad, especially since your patient is yelping in pain/fear, running around, shaking the injured foot, and generally not cooperating with your attempts to grab it with the towel. What I've done occasionally is stick the injured foot into a bucket of warm water with betadine solution. That starts the cleaning process, aids the containment process, and usually helps stop the bleeding process.

No betadine on hand? A bit of bleach -- a few mls into the bucket -- will do the job, although the smell of bleach is less pleasant than betadine.

No bucket handy? Pour water from a hose or vessel over the wound. If you've got a bottle of H2O2, pour that, but warn your patient that it will sting. It won't stop them from jumping around, but your holder will at least be ready to hold on tight.

You do have someone else holding your patient, right? No? Put your dog into the bathtub then, and run the warm water. You can clean up the trail of blood later with that bottle of H2O2 that you didn't get to use on the dog.

If you're not taking the dog to the vet, then gently flush out debris, pack with antibiotic or antiseptic ointment, cover with a nonstick bandage, and then wrap thoroughly and put a bootie on. I recommend taking your patient to your vet, unless you are your vet.

Those cuts bleed a lot, and the dog will be sore for a few days. A bigger cut or one that won't stop bleeding should be sutured (and then bandaged). Staying off the injured foot is easier in dogs than in humans.

As with any cut created in a dirty environment, make sure your dog is up-to-date on tetanus. It's such a simple vaccine, yet it prevents an incurable fatal condition.

It's handy for all sorts of things. It sticks to itself and it's soft and squishy, yet sturdy enough not to rip unless you want it to. You can knot it, strap things with it, tie things up with it, etc. Besides the obvious, of course, which is to use it for bandaging. Great stuff. Most feed stores carry it for less than $2 a roll.

#86: Why I, also, am not enthused about power saws, considering that my brother and I have a deformed finger each because we are, essentially, incompetent to operate doors properly.
Jim, could you do a post on nasty infections someday? I know it's not the sort of thing that one generally thinks of as emergency medicine, but I want an excuse to tell my cat-bite story (the one wherein I got used as a Bad Example for another patient, something of which I'm perversely proud).

My favorite story about equipment safety is the one that explains why Bob the SCAdian can keep all of his battle-ready sharp and pointies on the living room wall now that his family has bought their first house.

See, the first week after they moved in, he took the kids out to the back yard with his favorite weapon and a watermelon. He explained that a watermelon has approximately the same density as a child's skull and brains. Then he demonstrated what happens when you drop live steel on a watermelon. The kids don't go within touching distance of Dad's wall of sharp and pointies.

As a young man, my father worked with a team building and repairing grain elevators. One day he was up top looking at the bucket/conveyor. At the same time, his boss was leading a tour and turned on the bucket/conveyor without checking if anyone was near it. It scraped the palm of his hand off. Being a failed art student and in shock, Dad says all he could think about was how cool his tendons were. One trip to the hospital, and nothing was lost. Though he does have a great set of scars on his wrists.

James D. Macdonald @ 94: I have serious reservations about Doc Blue's recommendations. In his first point on Band-Aids (tm), he's wrong about moist wounds, wrong about povidone-iodine, and isn't following the current AHCPR or AHRQ guidelines for wound care.

It goes on from there. Alcohol does not sterilize the skin -- nothing sterilizes the skin. Iodine does not sterilize on contact; it requires contact time for disinfection.

Rather than take up space here, I can post on my LJ -- I've got a lecture on sterilants, disinfectants, and surgical prep that I need to review and update anyway. I'll put up a link if anyone wants that information.

Mostly I'm amazed by the price of what Doc Blue puts in his bag, and about how often I'd need most of that stuff.

For cleaning wounds all I use is saline or plain water if saline isn't available. I know we don't carry any iodine (outside of the prep pads for starting IVs) on the trucks.

On the other hand, I'm astounded by what's in the commercial first aid kits you get at Eastern Mountain Sports or wherever -- when I look at the list of what they have in 'em, I think "Wow, I hope no one carrying one of these things gets into trouble."

Cygnet, #91, I'm allergic to tape and adhesives now so I use that when I need to dress a cut. At the lab, they only use nursewrap, which is people-colored. You can buy vetwrap much cheaper and it comes in lovely colors. I have dark purple at the moment.

# 76: re: lie down beside your car during an earthquake, etc: That is HIGHLY controversial advice, by which I mean that most experts on the topic think it's wrong.

Yes, an overpass might collapse on top of your car. But it is much more likely that the overpass will stay where it is, while your car, not being anchored to the ground like the overpass is, will move on top of you and crush you, should you lie down next to it.

Generally, health and safety advice which comes via forwarded email should be checked out before being taken to heart or passed on.

More on the subject: www.earthquakecountry.info/dropcoverholdon

Snopes on that email: http://www.snopes.com/inboxer/household/triangle.asp

Thanks for the Snopes link. Yeah, I can't imagine lying down in front of or behind a car, even assuming that there would be time. Beside rather than under something heavy, though, generally seems like good advice.

And I didn't forward it. I brought it up here for the comments this group would bring to it. I was sloppy in that posting, apologies.

The standard earthquake advice is to get under sturdy objects, like heavy desks and tables, to keep smaller falling stuff from landing on you. I don't think there's much that will protect you from collapsing structures.

105: Don't get me wrong -- I use betadine too, daily. It's a good antiseptic; it's just not the highest level disinfectant that he makes it sound like. It's the first one we reach for when cleaning a wound, that's for sure. If you want killing on contact, then you want bleach at sterilant levels (1:5 dilution).

Well, when asked why she'd attended to the dog first she pointed out that the dog was in danger of bleeding out while the human's injury wasn't life-threatening.

Ginger @ 100

Do continue fleshing this out - I've often thought there was a lack of good, accessible info. on sterilization and disinfection, and which disinfectants work against which types of organisms. It's something I want to add into the wildlife health encyclopaedia I work on.

Is a timid, Piglet-like question appropriate for a first post? Specifically, regarding gloves in an emergency first aid situation.

Obviously, the first choice for gloves would be the nice (presumably sterile) ones intended specifically for medical/first aid use. These are something I don't generally have on hand. What I do generally have are non-sterile nitrile mechanic's gloves - the box is clearly labeled NOT FOR MEDICAL USE.

Am I correct in assuming that given the choice of bare hands or non-medical nitrile gloves, the gloves are still the preferred option?

I wonder why they're marked NOT FOR MEDICAL USE. One of my doctors has nitrile gloves in a holder on the wall so she can just pull them out. They're for examination use rather than wound care, but I'd think they'd be better in an emergency than bare hands.

As to why those might be marked "not for medical use"? Maybe something to do with the release agent from the molds? Or perhaps it has to do with the quality-control standards between medical and mechanics' gloves (how many have to be tested per 1,000 or summat).

You can buy boxes of nitrile exam gloves all over the place. (You don't want to use latex for all kinds of reasons, the big one being how many people have latex allergies.)

if the choice was between mechanics' gloves and no gloves at all, I'd go with the mechanics' gloves. I don't want what the patient's got, and the patient doesn't want what I've got.

109: What he said. Any glove is better than no glove. I suspect the "not for medical use" has to do with impermeability guarantees -- no flexible glove is 100% impermeable, but nitriles are less "holey" than latex, which is yet another good reason to use them.

In an emergency: Use the gloves you have, any gloves at all. Wash your hands in bleach solution if you have any concern at all about a potential exposure. Everything gets killed by a sterilant level of bleach (1:5 dilution is sterilant), including spores and mycobacterium tuberculosis (tb). If you did get exposed accidentally, you have a good chance of washing it off/out of you as long as you do this in a timely manner. A fifteen minute "scrub" is recommended, followed by a trip to your health care provider.

If you got a suspect exposure in the mucosal membranes (eyes, mouth) you can rinse with dilute bleach, but make it more dilute (1:18 or larger) as it will sting. Better yet, rinse with dilute betadine solution, about the color of "weak tea" (which of course, varies according to your definition of "weak" tea). Betadine is used to prep eyes for surgery, so it won't be so painful. Diluting betadine, by the way, makes it more "powerful" as an antiseptic. This is because the antiseptic part is the free Iodine ion (a free radical); betadine is Iodine bound lightly to a protein, so it is "tamed" Iodine. Putting it into a diluted solution means more Iodine comes off the proteins, generating those free radicals you need.

PJ at 104 (and everybody):
Actually, current earthquake advice is to get NEXT to something big and strong, and NOT under it. There are lots of void spaces in collapsed buildings, in predictable places.

Structural walls (away from windows) are the first choice of things to hunker down next to. If you can't get there FAST, hunker down next to whatever is very nearby and kinda strong. A bookcase, a table, the bedframe, whatever might partly hold up the rest of the building as it comes down around your ears.

Getting under those things is not as good an idea. If the bookcase collapses, under (or in front of it) is bad, but next to it there's a good chance there's still some void space. Under my partly collapsed bedframe will be filled with sharp splintery slats and smothery latex mattress. Next to it, though: probably some void space.

If you live in earthquakeland, you've already bolted the big, dangerous-when-falling-on-you objects to the wall, right? Of course you have. (And your water heater, too.)
So the old advice, to hide from "things" (besides the roof) that might fall on you, is not as sound as picking a spot that will stay uncrushed. Go for a likely void-space-to-be, curl up small, and cover up your neck with your arms.

Oh, and getting there fast? People apparently tend to break legs and ankles when running in an earthquake. The ground moves up and down, fast; each step you take that coincides with the ground moving upward becomes a MUCH harder slam. Ouch. So get to your void space as soon as you feel the first shock wave, before the shaking really starts.

(In the car, though, I think I'd stay in, and I'd stay belted in so I don't rattle around like a pebble in a rock-polishing tumbler.)

Terry Karney @ 46, etc, I seem to be more or less lucky: I can deal with sticking a needle in the cat (haven't had to stick needles in other people, but I imagine the principle would be similar) and with having needles stuck in me, but during the period of time in which I was giving myself intramuscular injections, it ranged from "semi-okay" to quite lightheaded, and I was always rather shaky afterwards.

It seems that the trick to getting stuck is walling off my consciousness of the needle in my body, and I can't wall it off when I'm doing the sticking. "Hello, I'm not here... Wait, I am! Hello, there's no needle here... Yes, there is!"

I wonder from time to time if I should train for an emergency response profession of one sort or another, though, because although I haven't dealt with massive trauma or dead people, my emotional response to emergency situations tends to be a state of total cold calm with some humor, and I've never been bothered by blood, mine or other people's.

Steff Z:
The high probability is that I'll be at work, in a fairly new (early 90s) highrise with some kind of shock absorbign system.
I'm going to be under the 'desk', because there's no 'next to' that's safe other than the service core of the building. (Under, also, because that way the computer monitors and keyboard (and the couple of reams of paper that inhabit the worksurface in my cube) can't easily fall on me.) Falling objects are more of a hazard than falling building, where I usually am.

Any wound you treat in the field is going to be contaminated. Go for "reasonably clean" rather than "sterile," because ... that's as good as you're going to get.

Once your patient is at the hospital all those nice sterile things will come out. And they'll be whacking your patient up with monstercillin ... provided your patient is alive. He won't die of sepsis in the first couple of hours. He may die of exsanguination in the first couple of minutes. You see where this is going.

=========

(One of the (many) reasons that I thought the movie Cabin Fever sucked was because when one of the spam-in-a-cabin young adults finally gets to a community hospital with a case of necrotizing fasciitis (AKA flesh-eating bacteria) the hospital staff's first reaction was to have a cop kill the patient and dump his body in a stream, rather than saying "Hot damn! A fun one!" and turning-to on fixing it. When we had a tourist show up in the ED at my hospital with NF we didn't dump her body in a stream, we got busy (and we got a nice thank-you card from her later, after it was all over).)

Here's a way to get an avulsion you want to avoid if at all possible: the deli meat slicer!

If you use one of these things, be aware that the blade is STILL SPINNING for some time after you flip the switch off.

I managed to take out half of my right middle fingernail and a chunk of skin by neglecting to notice that last Thursday.

According to the nice Occupational Health nurse today, I did all the right things: immediately stuck it under the cold water tap, applied pressure, and bandaged it firmly. I didn't realize that shock had set in until a couple of hours later, when it wore off and that bastard started HURTING.

If decent painkillers were available OTC in the US, I would have gotten a decent night's sleep and wouldn't have missed a work shift. As it was, I decided that sleeping in one-hour chunks had left me in no shape to operate a meat grinder the next morning, and betook myself to the ER, so I'd be sure to come in within 24 hours reporting for Workmen's Comp, because otherwise I'd have no way to pay for care if it got infected or something, and maybe the nice ER folks would give me a couple of painkillers besides.

No painkillers. A tetanus shot (sensible enough, but ouch!), a soak in Betadine (horrifyingly painful) and some special wound-clotting bandage, and a "not cleared to work until follow-up Monday." No earlier follow-up available, even though I was scheduled to work both weekend days. Crap.

Today's follow-up: an hour of progressive soaking (this time in non-painful saline and peroxide) and trimming to get the clotting gauze off my finger, Bacitracin and a fingertip Band-aid, a plastic protective splint to keep me from knocking it into things, and cleared to return to work. Follow-up Thursday.

I think my initial instinct of "there isn't anything for them to stitch, so why bother with the doctor?" was probably better. Now that my tetanus shot is up to date, if anything like this happens in the next five years, I think I won't BOTHER. I really didn't need to miss all this work.

I also think I'll be wearing lace gloves as a fashion accessory until my fingernail grows back (three months, the nurse estimated) and a protective mesh cutting glove when I need to use the slicer!

As I commented over in the current Open Thread, I had to get an avulsion case in to the emergency room last Friday. About a 3"x6" area on an older woman's leg, going down several layers in the skin. She'd gotten hurt in the morning in Florida and didn't want to miss her plane to Seattle. She'd wrapped it in two Ace bandages with some tissue. While I could get the Aces off, the tissue was well and truly bonded to her, and I didn't have saline to rinse it off and get it to release. She didn't want to go to the ER because it didn't hurt. I convinced her.

She's got an appointment at the Wound Clinic tomorrow morning. I've been cleaning the wound and changing the dressing daily.

This is not necessarily the best way to meet the girlfriend's terrifying 90=year-old mother for the first time. It seems to have worked, though.

I'll say. My partner (at that time, only a "partner-to-be") took care of me during my bout with mono (in which I sounded awful, due to enlarged tonsils, and slept all the time); this garnered her Major Brownie Points with my parents before they all met. My mother later told me that the only reason she didn't just fly down and take care of me was that she knew I had someone to do that.

As abi said, it's an excellent demonstration of the right kind of skills. Even I knew she was a keeper after that.

While it's an excellent demonstration of skills (fortunately, ones I have): on the whole, I'd rather be in Philadelphia, as WCFields' gravestone is reputed to say. Avoiding the wear and tear on outlaws (or even inlaws) is to be preferred.

Per the nice folks at Project Honeypot, 90.212.138.183 is an address known to be associated with spammers.

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